Αναδημοσίευση από το περιοδικό The Lancet (Vol 374 October 17, 2009), για να τονιστεί όχι τόσο ότι ο Ιπποκράτης ήταν ο πατέρας της Ιατρικής, αλλά και της Ιατρικής Ανθρωπολογίας... Ο ιατρός οφείλει να αποτελεί την γέφυρα μεταξύ πάθησης και παθόντος, να εξηγεί την πρώτη στον δεύτερο με λόγια απλά και κατανοητά και να προσπαθεί να παλέψει την πρώτη εκ μέρους του δεύτερου. Δυστυχώς, δεν είναι όμως πάντα έτσι.
Ευχαριστώ τον διευθυντή της κλινικής μου, που με έκανε κοινωνό αυτού του άρθρου.
"The art of medicine
Hippocrates and informed consent
Western medicine’s roots are in Ancient Greece where Hippocrates and his followers created an empirical medicine grounded in ethical promises. Most physicians are familiar with the Hippocratic Oath but they are less familiar with the remarkable medical texts of that era. Many modern medical ethicists, however, view the Greek physician–patient relationship as paternalistic, in which the physician concealed diagnostic or prognostic information from the patient. As Robert Veatch put it: “The old Hippocratic ethic saw the patient as a weak, debilitated, childlike victim, incapable of functioning as a real moral agent…The Hippocratic ethic is dead.” If Veatch is correct, a moral chasm separates modern medical ethics from ancient Greece. Such critics often cite Decorum as proving Greek paternalism. This work, however, portrays a more patrician physician than is depicted in the medical literature of The Oath’s time and scholars have also suggested that it dates to the early Christian era and that the text of Decorum is badly corrupted. To understand the ethics of the Oath, one must instead focus on works of the Cos school around 400 BC when Hippocrates was alive or in living memory. This Hippocratic canon includes theoretical works (eg, On Ancient Medicine and The Sacred Disease), clinical texts (eg, Aphorisms, Epidemics, and On Wounds in the Head), and ethical works (eg, The Oath). Collectively these books discuss minutiae from how to light a clinic or trim one’s fingernails before surgery to diseases, treatments, and case reports. The clinical texts illuminate the ethics of medicine.
Socially, the image of physicians haughtily dictating orders to Greek freemen seems at odds with the egalitarianism of Greek culture. Plato, writing soon after The Oath was written, discussed the voluntary and informed relationship between physicians and patients. The medical treatises of The Oath’s time depict an attractive model for physician–patient communication and securing consent. The first of the Aphorisms pointedly says: “The physician must be ready, not only to do his duty himself, but also to secure the cooperation of the patient.” Did Greek physicians secure the patient’s cooperation by coercion, deception, or persuasion?
The physician–patient conversation began with listening. Skill in listening was not taken to be self-evident. A gynecological treatise instructed physicians on how to listen to women: “You cannot disregard what women say about childbearing for they are talking about what they know and are always inquiring about…It is the women who make the judgments and who award the prize” (On the Seventh Month Child 4.1). The aim of listening was to discern a syndrome, the recognition of which was the basis for treatment because the underlying pathophysiology was entirely unknown. The discovery of germs, genes, and hormones lay in the distant future. It is difficult to recognize a syndrome. Many different diseases have fever, muscle aches, fatigue, and shortness of breath on exertion. To complicate matters further, the same disease will manifest itself and progress differently in different people. One person may die of pneumonia while another lives. The author of Prognosis despaired of naming diseases at all, “There is no point in seeking the name of any disease [for all] may be recognized by the same signs.”
To find a syndrome, Greek physicians undertook detailed histories and examinations. They noted the location and climate, age, sex, habits, household, and diet. They recorded rationality, mood, sleep, and dreams. Symptoms were carefully recorded, including appetite, thirst, nausea, the location and severity of pain, chills, coughs, sneezes, shivers, belching, flatulence, rigors, convulsions, nosebleeds, changes in menstruation, or failing vision or hearing. The physical examination paid attention to fever, patterns of breathing, paralysis, the color of the extremities, anatomy, and pain on palpation. Stools, urine, sputum, and vomit were described. Even such a comprehensive evaluation was insufficient without one additional observation: the course of a disease over time. Physicians observed the periodicity and trajectory of disease. The time it took for assessment posed a problem for the conversation with the patient. When, if ever, should the patient be told the prognosis? It is easy to misinterpret the Greek advice to take time to observe the course of an illness as implying that the physician should conceal or withhold a prognosis.
Statements like “In the case of acute diseases, to predict either death or recovery is not quite safe (or not at all safe)” (Aphorisms II:xix), or “[It] is not safe to make an advance statement before the disease is settled” (Prorrhetic II:3) do not endorse a paternalistic silence. The commendation to observe the course of illness commends a prudent accuracy similar to the way a modern physician waits for biopsy or scan results before telling a patient the nature of a cancer. As the author of Prorrhetic II cautions, prognosis, “is indeed possible [but]…I advise you to be as cautious as possible… When you are successful in making a prediction you will be admired by the patient you are tending, but when you go wrong you will not only be subject to hatred, but perhaps even be thought mad.”
The disclosure of the prognosis to a patient and to the patient’s family benefited both patient and physician. Affections recommends telling patients what medicine can offer: “Any man who is intelligent must, on considering that health is of the utmost value to human beings, have the personal understanding necessary to help himself in diseases and be able to understand and to judge what physicians say and what they administer to his body, being versed in each of these matters to a degree reasonable for a layman.” This admonition to speak plainly is repeatedly emphasized, for example, in On Ancient Medicine: “if anyone departs from what is popular knowledge and does not make himself intelligible to his audience, he is not being practical”. Forthright speech is also recommended when the treatment plan is not followed. As Prorrhetic II puts it, “the physician should indicate whatever is abnormal; for evils that arise as a result of non-compliance will be revealed as such, since the shortness of breath and the rest of the symptoms will cease on the following day, if they arose only because of a dietary mistake”.
Finally, open disclosure of prognosis directly benefited the physician’s business: “[If a physician] is able to tell his patients…not only about their past and present symptoms, but also tell them what is going to happen as well as to fill in the details they have omitted, he will increase his reputation…and people will have no qualms in putting themselves under his care“ (Prognosis 1). The Greek physicians strongly believed that bad news, like good, should be disclosed. For example, the author of Diseases I says that it is “incorrect to say that a disease is different from what it really is, to say that a major disease is minor, or to say that a minor disease is major; not to tell a patient that is going to survive that he will survive, not to tell a patient about to die that he will die…[or not] to say that what cannot be cured will be cured.” The author of On Head Wounds has similar advice: “When a patient is likely to die from his head wounds and cannot recover his health or be saved, it is by means of the following signs, then you must make the diagnosis that he is going to die and predict what is going to be.”
Some Greek scholars argue that good and bad prognoses were to be disclosed because medical prognostication was a secular analogue of divination in which favorable and unfavorable prophecies were made. What follows is an example of the entire sequence description, diagnosis, and disclosure of a syndrome we call tetanus. Here is the syndromic description: “If in a person suffering from a fever, the neck be suddenly twisted round and swallowing becomes almost impossible though there is no swelling, then he will die” (Aphorisms VII:59a). Here is the diagnosis and disclosure: “The commander of the large ship: the anchor crushed his forefinger, the bone below it on the right hand. Inflammation developed, gangrene…Part of the finger fell away…After that, problems with the tongue, he said he could not articulate anything. Prediction made that opisthonis [the lethal climax of tetanus] would come. His jaws became fixed together, then it went to the neck, on the third day he was entirely convulsed backward, with sweating. On the sixth day after the prediction, he died” (Epidemics 5:74).
It seems that European doctors forgot and only recently rediscovered what our Greek ancestors knew. The doctor– patient relationship rests on honesty. Patients trust a doctor who accurately tells them how their disease will unfold and what treatment will and will not do for them. The family and friends of that Greek ship commander knew that it was time to gather. It is thought provoking to consider that the replacement of syndromes with pathophysiology based diagnoses may have displaced the sharing of honest prognoses. Consider the difference between these two ways of disclosing the same illness. “You have a Glioblastoma, grade IV. We have some new therapies”. Or “You have a condition that is painlessly progressive and without fever destroying your ability to see and move. Seizures sometimes happen to people who have this. It progresses over a few seasons. Our treatments have little effect.” Although the distinction is between the pathophysiology and syndromic disclosure, it is easy to see which approach obfuscates and which—grounded in the patient’s experience of the syndrome—communicates. It is easy to see which one more directly points the patient to the necessary life decisions. It is easy to see which one anticipates the need for trust as the disease unfolds as it will."
